|
Section Name |
Field Name |
Field and/or Section Description |
|
TITLE ACORD 2 (2008/01) |
Automobile Loss Notice |
Use the ACORD Automobile Loss Notice (ACORD 2) for the reporting of both commercial and personal lines automobile losses. |
|
IDENTIFICATION SECTION |
Date |
Enter the Month/day/year on which the form is completed. (MM/DD/YYYY) |
|
IDENTIFICATION SECTION |
Agency |
Enter the Agency's name and address. |
|
IDENTIFICATION SECTION |
Contact Name |
Enter the name individual at the agency that is the primary contact. |
|
IDENTIFICATION SECTION |
Phone (A/C, No, Ext) |
Enter the Agency's telephone number. |
|
IDENTIFICATION SECTION |
FAX |
Enter the Agency's fax number. |
|
IDENTIFICATION SECTION |
E-Mail Address |
Enter the Agency's e-mail address. |
|
IDENTIFICATION SECTION |
Code |
Enter the Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. |
|
IDENTIFICATION SECTION |
Subcode |
Enter the appropriate code, if your agency uses a sub-code identification system with the company. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter the customer’s identification number assigned by the agency. |
|
IDENTIFICATION SECTION |
Insured Location Code |
Enter the code the policyholder defines that is used to allocate loss experience to cost centers. For example, if a grocery store chain is insured and the entire chain was under one policy, the grocery store chain might choose to allocate the losses for each store. To do this they would provide a store number or store code (something the insured defines) when they report a claim. The insured would include that store number in the "Insured Location Code" field so that the carrier can record the code in their claim system and then the right store is assessed the loss experience. |
|
IDENTIFICATION SECTION |
Date & Time of Loss |
Enter the date and approximate time that the loss occurred. |
|
IDENTIFICATION SECTION |
AM or PM |
Check the appropriate A.M. or P.M. box should be checked (e.g., 01/11/1994 - 12:15 A.M.). |
|
IDENTIFICATION SECTION |
Carrier |
Enter the company name for commercial or personal property, homeowner, dwelling fire, inland marine and similar type policies.and policy number for the types of policies written. Use the actual name of the company within the group to which you are sending the loss notice. Do not use group names. |
|
IDENTIFICATION SECTION |
NAIC Code |
Enter the NAIC code of the insurance company that issued the policy. |
|
IDENTIFICATION SECTION |
Policy Number |
Enter the policy number exactly as it appears on the policy, including prefix and suffix symbols. |
|
IDENTIFICATION SECTION |
Policy Type |
Enter the type of policy issued to the insured. e. g., personal auto, truckers, garage liability. |
|
INSURED |
Name of Insured |
Enter the full name of the insured (First, Middle, Last name) as found on the declarations page of the policy. |
|
INSURED |
Date of Birth |
Enter the date of birth for the insured. |
|
INSURED |
Soc. Sec. # |
Enter the social security number for the insured. |
|
INSURED |
Marital Status |
Enter the insured's marital status. |
|
INSURED |
Primary Phone |
Enter primary telephone number including area code. |
|
INSURED |
Home |
Check if Primary Phone is Home |
|
INSURED |
Bus |
Check if Primary Phone is Business |
|
INSURED |
Cell |
Check if Primary Phone is Cell |
|
INSURED |
Secondary Phone |
Enter secondary telephone number including area code. |
|
INSURED |
Home |
Check if Secondary Phone is Home |
|
INSURED |
Bus |
Check if Secondary Phone is Business |
|
INSURED |
Cell |
Check if Secondary Phone is Cell |
|
INSURED |
Insured's Mailing Address |
Enter the mailing address of the insured as found on the declarations page of the policy. |
|
INSURED |
Primary E-Mail Address |
Enter the primary e-mail address of the insured. |
|
INSURED |
Secondary E-Mail Address |
Enter the secondary e-mail address of the insured. |
|
CONTACT |
Contact Insured |
Check this box, if the individual to contact for information is the same as the named insured, and leave blank the areas for contact name, address and phone numbers. |
|
CONTACT |
Name of Contact |
Enter the full name (First, Middle, Last) of the individual to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is needed if the 'Contact Insured' option is checked. |
|
CONTACT |
Primary Phone |
Enter primary telephone number including area code. |
|
CONTACT |
Home |
Check if Primary Phone is Home |
|
CONTACT |
Bus |
Check if Primary Phone is Business |
|
CONTACT |
Cell |
Check if Primary Phone is Cell |
|
CONTACT |
Secondary Phone |
Enter secondary telephone number including area code. |
|
CONTACT |
Home |
Check if Secondary Phone is Home |
|
CONTACT |
Bus |
Check if Secondary Phone is Business |
|
CONTACT |
Cell |
Check if Secondary Phone is Cell |
|
CONTACT |
When to Contact |
Describe the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.). |
|
CONTACT |
Contact's Mailing Address |
Enter the mailing address of the contact as found on the declarations page of the policy. |
|
CONTACT |
Primary E-Mail Address |
Enter the primary e-mail address of the contact. |
|
CONTACT |
Secondary E-Mail Address |
Enter the secondary e-mail address of the contact. |
|
LOSS |
Location of Loss Street |
Enter the physical street location of the loss. If the insured has multiple locations on the policy, include the policy location number and building number (e.g., insured’s home or Loc 3, Bld 2; 151 Main St). |
|
LOSS |
Location of Loss City, State, Zip |
Enter the city, state and zip code for the physical location of the loss. |
|
LOSS |
Location of Loss Country |
Enter the country for the physical location of the loss. |
|
LOSS |
Police or Fire Department Contacted |
Enter the name of the municipal or county police or fire department to which the loss was reported, including the precinct or station number if available. |
|
LOSS |
Report Number |
Enter the report number, if a report was issued. |
|
LOSS |
Description of Accident |
Descibe how the accident occurred. |
|
INSURED VEHICLE |
Veh. No. |
Enter the vehicle number assigned to the vehicle as it appears on the policy declarations page. |
|
INSURED VEHICLE |
Year |
Enter the model year of the vehicle. |
|
INSURED VEHICLE |
Make |
Enter the vehicle’s manufacturer (e.g., Buick). |
|
INSURED VEHICLE |
Model |
Enter the manufacturer’s model name (e.g., Regal). |
|
INSURED VEHICLE |
Body Type |
Enter the vehicle’s body type (e.g., two-door sedan). |
|
INSURED VEHICLE |
V.I.N. |
Enter the full Vehicle Identification Number. |
|
INSURED VEHICLE |
Plate No. |
Enter the license plate number. |
|
INSURED VEHICLE |
State |
Enter the state of issuance for the license plate. |
|
INSURED VEHICLE |
Owner is insured |
Check if the owner of the vehicle is the insured. |
|
INSURED VEHICLE |
Owner’s Name & Address |
Enter the name and address of the owner of the vehicle, if not the insured. |
|
INSURED VEHICLE |
Primary Phone |
Enter primary telephone number including area code. |
|
INSURED VEHICLE |
Home |
Check if Primary Phone is Home |
|
INSURED VEHICLE |
Bus |
Check if Primary Phone is Business |
|
INSURED VEHICLE |
Cell |
Check if Primary Phone is Cell |
|
INSURED VEHICLE |
Secondary Phone |
Enter primary telephone number including area code. |
|
INSURED VEHICLE |
Home |
Check if Secondary Phone is Home |
|
INSURED VEHICLE |
Bus |
Check if Secondary Phone is Business |
|
INSURED VEHICLE |
Cell |
Check if Secondary Phone is Cell |
|
INSURED VEHICLE |
Primary E-Mail Address |
Enter the primary e-mail address of the insured. |
|
INSURED VEHICLE |
Secondary E-Mail Address |
Enter the secondary e-mail address of the insured. |
|
INSURED VEHICLE |
Driver is owner |
Check if the driver is the owner. Otherwise, provide the driver’s name and address. |
|
INSURED VEHICLE |
Driver’s Name & Address |
Enter the driver’s name and address, if not the insured. |
|
INSURED VEHICLE |
Primary Phone |
Enter primary telephone number including area code. |
|
INSURED VEHICLE |
Home |
Check if Primary Phone is Home |
|
INSURED VEHICLE |
Bus |
Check if Primary Phone is Business |
|
INSURED VEHICLE |
Cell |
Check if Primary Phone is Cell |
|
INSURED VEHICLE |
Secondary Phone |
Enter primary telephone number including area code. |
|
INSURED VEHICLE |
Home |
Check if Secondary Phone is Home |
|
INSURED VEHICLE |
Bus |
Check if Secondary Phone is Business |
|
INSURED VEHICLE |
Cell |
Check if Secondary Phone is Cell |
|
INSURED VEHICLE |
Primary E-Mail Address |
Enter the primary e-mail address of the insured. |
|
INSURED VEHICLE |
Secondary E-Mail Address |
Enter the secondary e-mail address of the insured. |
|
INSURED VEHICLE |
Relation to Insured |
Enter the relationship between the driver and the insured (e.g., Insured, wife, child). |
|
INSURED VEHICLE |
Date of Birth |
Enter the driver’s birth date. |
|
INSURED VEHICLE |
Driver’s License Number |
Enter the driver’s license number. |
|
INSURED VEHICLE |
State |
Enter the state of issuance of the driver’s license. |
|
INSURED VEHICLE |
Purpose of Use |
Enter a short description of the purpose of the trip during which the accident occurred (e.g., trip to store or commuting to work). |
|
INSURED VEHICLE |
Used With Permission? |
Enter Y for a “Yes” and N for “No” to indicate if the vehicle was used with permission. |
|
INSURED VEHICLE |
Describe Damage |
Describe any damage to the insured’s vehicle (e.g., right front fender crushed). |
|
INSURED VEHICLE |
Estimate Amount |
Enter an estimate for the cost of repairing the vehicle. |
|
INSURED VEHICLE |
Where Can Vehicle Be Seen? |
Describe where the adjuster can inspect the vehicle. If other than at the insured’s address, include the address. |
|
INSURED VEHICLE |
When Can Vehicle Be Seen? |
Describe the time period the vehicle is available for inspection. |
|
INSURED VEHICLE |
Other Insurance On Vehicle -Carrier |
Enter the company name on any other applicable insurance. Enter "N/A" if none. |
|
INSURED VEHICLE |
Other Insurance On Vehicle -Policy Number |
Enter the policy number on any other applicable insurance. Enter "N/A" if none. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Customer’s identification number assigned by the agency. |
|
PROPERTY DAMAGED |
Non-Vehicle ? |
Check this box to indicate the damaged property is a not a vehicle. |
|
PROPERTY DAMAGED |
Veh # |
Enter the vehicle number assigned to the vehicle as it appears on the policy declarations page. |
|
PROPERTY DAMAGED |
Year |
Enter the year of the damaged vehicle. |
|
PROPERTY DAMAGED |
Make |
Enter the make of the damaged vehicle (e.g, Ford). |
|
PROPERTY DAMAGED |
Model |
Enter the model of the damaged vehicle (e.g., Taurus). |
|
PROPERTY DAMAGED |
Body Type |
Enter the vehicle’s body type (e.g., two-door sedan). |
|
PROPERTY DAMAGED |
V.I.N. |
Enter the full Vehicle Identification Number. |
|
PROPERTY DAMAGED |
Plate Number |
Enter the plate number of the damaged vehicle, including the state (e.g., NY 334 XJ). |
|
PROPERTY DAMAGED |
State |
State of issuance for the license plate. |
|
PROPERTY DAMAGED |
Describe Property (Other Than Vehicle) |
Describe the other type of property damaged, such as home or fence. |
|
PROPERTY DAMAGED |
Other Veh./Prop. Ins? |
Enter Y for a “Yes” and N for “No” to indicate if the damaged property (or vehicle) is insured or not. |
|
PROPERTY DAMAGED |
Carrier or Agency Name |
Enter the name of the insurance company or agency covering this property (or vehicle). |
|
PROPERTY DAMAGED |
NAIC Code |
Enter the NAIC code of the insurance company that issued the policy. |
|
PROPERTY DAMAGED |
Policy # |
Enter the policy number for this property (or vehicle). |
|
PROPERTY DAMAGED |
Owner’s Name & Address |
Enter the name and address of the owner of the property (or vehicle). |
|
PROPERTY DAMAGED |
Primary Phone |
Enter primary telephone number including area code. |
|
PROPERTY DAMAGED |
Home |
Check if Primary Phone is Home |
|
PROPERTY DAMAGED |
Bus |
Check if Primary Phone is Business |
|
PROPERTY DAMAGED |
Cell |
Check if Primary Phone is Cell |
|
PROPERTY DAMAGED |
Secondary Phone |
Enter primary telephone number including area code. |
|
PROPERTY DAMAGED |
Home |
Check if Secondary Phone is Home |
|
PROPERTY DAMAGED |
Bus |
Check if Secondary Phone is Business |
|
PROPERTY DAMAGED |
Cell |
Check if Secondary Phone is Cell |
|
PROPERTY DAMAGED |
Primary E-Mail Address |
Enter the primary e-mail address of the insured. |
|
PROPERTY DAMAGED |
Secondary E-Mail Address |
Enter the secondary e-mail address of the insured. |
|
PROPERTY DAMAGED |
Driver address same as owner |
Check the box if the drivers address is the same as the owner’s name and address. |
|
PROPERTY DAMAGED |
Driver’s Name & Address |
Enter the name and address of the driver of the other vehicle, if the property damaged is another vehicle. |
|
PROPERTY DAMAGED |
Primary Phone |
Enter primary telephone number including area code. |
|
PROPERTY DAMAGED |
Home |
Check if Primary Phone is Home |
|
PROPERTY DAMAGED |
Bus |
Check if Primary Phone is Business |
|
PROPERTY DAMAGED |
Cell |
Check if Primary Phone is Cell |
|
PROPERTY DAMAGED |
Secondary Phone |
Enter primary telephone number including area code. |
|
PROPERTY DAMAGED |
Home |
Check if Secondary Phone is Home |
|
PROPERTY DAMAGED |
Bus |
Check if Secondary Phone is Business |
|
PROPERTY DAMAGED |
Cell |
Check if Secondary Phone is Cell |
|
PROPERTY DAMAGED |
Primary E-Mail Address |
Enter the primary e-mail address of the insured. |
|
PROPERTY DAMAGED |
Secondary E-Mail Address |
Enter the secondary e-mail address of the insured. |
|
PROPERTY DAMAGED |
Describe Damage |
Describe the extent of the property damaged (e.g., porch pillar broken, right front fender crushed). |
|
PROPERTY DAMAGED |
Estimate Amount |
Enter an estimate of the cost of repair. |
|
PROPERTY DAMAGED |
Where Can Damage Be Seen? |
Descibe where the damaged property is located, including address, so that an adjuster can inspect it. |
|
INJURED |
Name & Address |
Enter the name(s) and address(es) of any people injured in the accident. |
|
INJURED |
Phone |
Enter the home telephone number, including area code of any injured party. |
|
INJURED |
PED |
Check if the injured party was a pedestrian by an "X" in this box. |
|
INJURED |
Ins. Veh. |
Check if the injured party was in the insured’s vehicle by an "X" in this box. |
|
INJURED |
Other Veh. |
Check if the injured party was in a vehicle other than the insured’s by an "X" in this box. |
|
INJURED |
Age |
Enter the age of the injured party. |
|
INJURED |
Extent of Injury |
Describe the injury to the injured party (e.g., broken left leg). |
|
WITNESSES OR PASSENGERS |
Name & Address |
Enter the name(s) and address(es) of any witnesses or uninjured passengers. |
|
WITNESSES OR PASSENGERS |
Phone |
Enter the home telephone number, including area code, of any witness or passenger. |
|
WITNESSES OR PASSENGERS |
Ins. Veh. |
Check if the witness or passenger was in the insured’s vehicle by an "X' in this box. |
|
WITNESSES OR PASSENGERS |
Other Veh. |
Check if the witness or passenger was in a vehicle other than the insured’s by an "X" in this box. |
|
WITNESSES OR PASSENGERS |
Other |
Describe any other witnesses. If they were not in the insured’s vehicle or other involved vehicle, include the location from which they witnessed the incident. |
|
WITNESSES OR PASSENGERS |
Reported By |
Enter the name of the individual that reported the loss. |
|
WITNESSES OR PASSENGERS |
Reported To |
Enter the name of the individual that the loss was reported too. |
|
WITNESSES OR PASSENGERS |
Remarks |
Describe any other additional information that will assist in properly reporting and settling this claim. Include the adjuster’s name if known. |
